Care Manager - RN

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Responsible for the assessment, reassessment, care planning and coordination of care and services. Includes ongoing monitoring of an appropriate and effective person centered care plan, member education and care management. Regularly communicates with the member?s PCP and other providers, and integrates the member, caregiver and other provider feedback into the assessment and planning.

ESSENTIAL FUNCTIONS:- Ensures continuity of care for newly enrolled members.- Identifies and prioritizes the member?s needs and preferences. Develops quantifiable goals and desired outcomes, and promotes the member?s ability to self-manage to the greatest extent possible.- Develops, implements and monitors the Person Centered Service Plan, assisting members in obtaining reasonable accommodations when appropriate.- Manages case load, including risk stratification of members, monitoring reassessment needs and facilitating transitions of care settings.- Serves as the primary point of member contact. Assesses member needs, manages care and services, and ensures effective communication among members, caregivers, providers and community supports.- As the lead of the interdisciplinary team, facilitates the activities and communication within an interdisciplinary team of providers, vendors, facilities, discharge planners, field nurses, social workers, care coordinators, and member/caregivers to effectively manage care plans and transitions of care settings.- Maintains timely, complete and accurate documentation using both hard copy and technology based solutions in compliance with regulatory policies and procedures. - Gathers and summarizes data for reports.- Supports initiatives of the Quality Assessment and Performance Improvement Committee.- All other duties as assigned.